A. Problem Analysis

1. What was the problem before the implementation of the initiative?

Acute malnutrition of children in the age group of 0-5 years is one of the biggest problem facing India today. Prevalence of malnutrition among children of 0-5 year’s age group is also a serious cause of concern for Gujarat too. Malnutrition is directly and indirectly associated with under five and infant mortality.
Gujarat Government accelerated its efforts to achieve MDG 4to reduce under 5 mortality to at least as low as 12 per 1000 live births by 2030. Now malnutrition is addressed under SDG 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture to reduce child mortality in the context of SDG. But the need was felt to address all the forms of under nutrition considering the developmental paradox in Gujarat.Infant Mortality in Gujarat is 33/1000 live births and under five mortality is 39/1000 live births (SRS 2015). As per WHO fact sheet N.178 of September 2014, malnourished children, particularly those with severe acute malnutrition (SAM) have a higher risk of death from common childhood illness such as diarrhea, pneumonia and malaria. Nutrition related factors contribute to about 45% of deaths in children under five years of age.A severely wasted child, who is termed as a child having Severe Acute Malnutrition (SAM), has nine times higher risk of mortality as compared to other children. If under-5 Mortality Rates (U5MR) are to be reduced in the State, it is imperative to address the problem of wasting and focus on the management of children with SAM.
According to the National Family Health Survey (NFHS) 2005-2006, the prevalence of stunting is 46%, 44.3% are underweight and 18.7% are wasted in Gujarat. Prevalence of Acute Severe Malnutrition (SAM) was 5.8% (NFHS-3) and 6.7% (RSOC 2014).

B. Strategic Approach

2. What was the solution?

In order to mitigate the problem of Severe Acute Malnutrition (SAM), Gujarat Government started the Kuposhan Mukt Gujarat Maha-Abhiyan in year 2015. In 2015 screening of 0-5 year’s children was carried out to assess the malnutrition status and to identify severely acute malnourished children. After identification, SAM children were givenfacility based/community based treatment.There was no monthly information system for beneficiary based tracking of the nutritional status of the children. Online MIS was developed for beneficiary based tracking of each and every child of 0-5 years of age. Also all SAM identified are followed up to 2 years on monthly basis to review the health and nutrition status.

3. How did the initiative solve the problem and improve people’s lives?

Under "Kuposhan Mukt Gujarat Maha-Abhiyan (KMGA)Phase –I was implemented form May-2015 to August-2015 and phase II was implemented from June 2016 to August 2016. In phase-I around 43 lakh children and in phase-2 around 50.32 lakh children were screened based on the weight for height, weight for age, pitting edema and Mid upper arm circumference. Total 47,930 SAM children were identified. Out of 47,955 SAM identified 21,612 children were admitted at Child Malnutrition Treatment Centre (CMTC) / Nutrition Rehabilitation Centre (NRC) and 30,291 children were admitted under Community Based Management of Acute Malnutrition (CMAM) for 8-12 weeks treatment with Bal Amrutam (Ready To Use Therapeutic Food (RUTF). 10,868 SAM children gained weight more than 5gm/kg/day at CMTC/NRC. Under CMAM program 12,137 children have been cured out of 20,524 discharged children from the treatment. Under the CMAM the stay at facility was reduced rendering the facility to continue the whole treatment for the period of 8 to 12 weeks after the facility stay of 14 days. Because of the continuation of the treatment, the cure rate was increased upto 60%. Also the community became aware about the nutritional status of their child and its treatment with the proper diet and medications. The out of pocket expenditure was reduced.

C. Execution and Implementation

4. In which ways is the initiative creative and innovative?

This was the first time in the world that almost 50 Lakhs children of 0-5 year’s age group were screened for malnutritionas per WHO guideline. Also children identified with SAM weremanaged with integrated approach by facility and community based management. Recording of Nutrition Parameters, Treatment, and Follow up data was captured in e-Mamta i.e. Online MIS system developed by Government of Gujarat.

5. Who implemented the initiative and what is the size of the population affected by this initiative?

This initiative was implemented by Dept of Health and Family Welfare, Govt of Gujarat under the banner of Kuposhan Mukt Gujarat Maha-Abhiyan. Total 43 lakhs children of 0 to 5 years were screened in the year 2015 and almost 50 Lakhs children of 0 to 5 years age group were screened under this initiative in the year 2016.

6. How was the strategy implemented and what resources were mobilized?

Under "Kuposhan Mukt Gujarat Maha-Abhiyan (KMGA)" frontline health workers carried out the screening of 0 to 5 years children to evaluate the malnutrition status. Facility based or community based management of the children were carried out based on their nutrition status & medical complication.Under this campaign, SAM children who failed appetite test and/or with medical complications were referred& treated at Child Malnutrition Treatment Centre (CMTC) / Nutrition Rehabilitation Centre (NRC) and those who were appetite test pass and without medical complications were admitted and managed under Community Based Management of Severe Acute Malnutrition (CMAM) for 12 weeks with Bal Amrutam (Complementary Therapeutic Food). Bal Amrutam is a therapeutic food, homogenously prepared as per the WHO guideline. UNICEF played a major role as a technical partner. Guideline and protocols for campaign were developed with the support of UNICEF. Almost 50,000 health personnel were trained to carry out this activity. UNICEF allocated grant for training health personnel at State & District level. Government of Gujarat allocated the budget of 30 Crores for the management of SAM children at facility level as well as for purchasing of Bal Amrutam.

7. Who were the stakeholders involved in the design of the initiative and in its implementation?

The planning, funding and implementation of the program was carried out by Department of Health and Family Welfare. Program advocacy, strategy planning. Technical inputs, guideline development & training were supported by UNICEF. Capacity building was done with the support of faculties from medical colleges. Support in program implementation at ground level was done by Department of Woman & Child. Procurement, quality testing, supply chain management were managed by Gujarat Medical Services Corporation Limited (GMSCL). Ms. Amul (Anand,Gujarat) produced and supplied Bal Amrutam.

8. What were the most successful outputs and why was the initiative effective?

Almost 43 lakh children in phase-1 and almost 50.32 lakh children were screened under "Kuposhan Mukt Gujarat Maha-Abhiyan (KMGA) Phase II" identification of 47,955 SAM children of age group 0-5 years was done from June to August 2016. Total 10,868 SAM children have gained weight of more than 5gm/kg/day at CMTC/NRC. Under CMAM, 12,137 (59.14%) children were cured.

9. What were the main obstacles encountered and how were they overcome?

The main obstacles were:
• Equipments (Stadiometer, Infantometer) for screening of children were not sufficiently available&caliberated at all health facilities. To overcome this gap 15000 equipments were procured and supplied.
• Unavailability of any energy dense food to treat SAM children at community level. This was overcome by supply of BalAmrutam which was prepared according to WHO formula in conjugation with Ms. AMUL Dairy.
• It was found difficult for health workers to classify the children in SAM & MAM as per the complicated Z-score chart of WHO. So, an android mobile application named ChildNutriCalc (Available on Google Playstore) was developed which proved user friendly for health workers to calculate weight for height/length SD on the basis of parameters like Height/length, weight and age of child.
• Case based recording of screened children was not available. So an online MIS was developed in e-Mamta, which made possible to track each and every child individually.

D. Impact and Sustainability

10. What were the key benefits resulting from this initiative?

Under Kuposhan Mukt Gujarat Maha-Abhiyan Phase II total 50.32 Lakhs children of 0-5 years age group were screened for Severe Acute Malnutrition. The key result of Phase II indicates 47,955 SAM children. Amongst which 21,612 children were admitted at CMTC/NRC and 30,291 children had been admitted under CMAM for 8-12 week treatment of Bal Amrutam (RUTF) on the basis of assessment for Appetite test and medical complications. Out of total 21,612 SAM children admitted at CMTC/NRC, 10,868 SAM children have gained weight more than 5gm/kg/day at CMTC/NRC. Under CMAM we got 12,137 (59.14%) children cured out of 20,524 discharged children from the treatment.

11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

Yes, under the CMAM program the community became more aware about the nutritional status of their child and became more aware about the diet to cure the malnutrition. More and more people got benefited which improved faith of the community in the public health care delivery system. Community became more empowered for the treatment and management of the malnutrition.

12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

Yes, this initiative benefits the most vulnerable age group as it focuses mainly on target group of 0-5 yrs aged children.